Shifting Place of Death of Children in the United States, 1999-2023

Recent increases in pediatric all-cause mortality have highlighted significant disparities based on race, ethnicity, age, sex, and cause of death. Our aim is to explore where these deaths occur, which is critical for designing interventions to mitigate these worrying trends.

Mortality data for children under 18 years of age from 1999 to 2023 were obtained from the Centers for Disease Control and Prevention's Wide-ranging ONline Data for Epidemiologic Research database, categorizing deaths by place [inpatient, emergency department (ED)/outpatient, dead on arrival, and other]. Place of death was stratified by demographic factors including age, race, ethnicity, gender (sex), and cause of death. Crude mortality rates were calculated using population estimates, and trends were analyzed using joinpoint regression to identify inflection points and annual percentage change (APC).

Distribution of deaths by place has shifted over time. ED/outpatient deaths decreased between 2006 and 2012 (APC: -3.28, P = 0.001), a trend that was reversed between 2019 and 2023 (APC: 4.22, P < 0.001). Similarly, deaths in the home decreased significantly from 2006 to 2010 (APC: -9.59, P < 0.001) before increasing significantly between 2018 and 2023 (APC: 5.59, P < 0.001). Black children had elevated mortality rates in inpatient, ED/outpatient, home, and other settings, with the greatest overall increase seen in ED/outpatient deaths in black children (APC: 9.66, P = 0.014).

This study identifies significant trends and disparities in pediatric mortality by place of death. Enhanced surveillance and targeted interventions are essential to address the underlying causes of these disparities and reduce pediatric mortality across all settings.